Reflections on the trends of suicide in Sri Lanka, 1997-2022: The need for continued vigilance.

Despite reductions in suicide rates in Sri Lanka during the past decades, largely by introduction of national bans on highly hazardous pesticides, the country continues to record a higher than global average rate of suicide. With the changing availability of methods of suicide over time, we aimed to examine the age-standardized suicide rates in Sri Lanka by sex, age, and method between 1997 to 2022 using national police suicide data to identify trends. The rate of suicide in Sri Lanka in 2022 was 27/100,000 and 5/100,000, in males and females respectively, with an overall suicide rate of 15/100,000 population. When considering the previous decades, the overall rate of suicide has declined from 1997 until about 2015, in both sexes, driven by a drop in the numbers of suicides due to pesticide ingestion. In females the overall rates of suicide plateaued around 2015, but in males there has been an upward trend in overall suicide that started in 2016, mostly due to an increase in rates of hanging. Since 2016 rates of suicide by hanging have increased among older males, and young females (17-25 years). Whilst the current suicide rate in Sri Lanka is substantially lower than it was during the 1990s, the upward trend in hanging seen in the last few years, particularly among older men and young women, is of concern. Ongoing monitoring of suicide rates should be a priority during the next few years, to detect and respond to changes as soon as possible. There is an urgent need to address current risk factors for suicide in Sri Lanka, such as significant financial insecurity, unemployment, depression, alcohol misuse, and domestic violence, and to minimize media glamourization of hanging by suicide.

Intimate partner violence, suicide and self-harm in Sri Lanka: Analysis of national data.

There is increasing evidence from South Asia and internationally that intimate partner violence (IPV) is strongly associated with self-harm, however its association with suicide and self-harm has not been extensively examined, nor has this relationship been explored at a national level. Using national datasets, area-level variation in IPV, suicide and self-harm in Sri Lanka were examined. In addition, the association between individual level exposure to past-year IPV and non-fatal self-harm by any household member were explored in a series of multi-level logistic regression models, adjusting for age. Similar patterns in the distribution of suicide and IPV were found, with higher rates evident in post-conflict districts, specifically Batticaloa, Kilinochchi, and Mullaitivu. Experience of past year IPV and its various forms were strongly associated with household-level self-harm in the past year (adjusted odds ratio [AOR] = 3.83 95% CI 2.27-6.46). A similar magnitude was found for physical/sexual abuse (AOR 5.17 95% CI 2.95-9.05) and psychological abuse (AOR 4.64 95% CI 2.50-7.00). A dose-response association was also evident for frequency of abuse, with an increasing risk of household-level self-harm for women reporting abuse 'less often' (AOR 2.95 95% CI 1.46-5.92), and abuse experienced 'daily, weekly, or monthly' (AOR 4.83 95% CI 2.59-9.00), compared to no abuse. This study contributes to a growing body of evidence on the relationship between IPV and suicidal behaviour in South Asia. Addressing IPV and its various forms should be a priority for suicide prevention in Sri Lanka, alongside trauma-informed approaches in post-conflict settings.

The Cost-Effectiveness of Psychosocial Interventions Following Self-Harm in Australia.

Background: Psychosocial interventions following self-harm in adults, in particular cognitive behavioral therapy (CBT), can be effective in lowering the risk of repeated self-harm. Aims: To evaluate the cost-effectiveness of CBT for reducing repeated self-harm in the Australian context. Method: The current study adopted the accessing cost-effectiveness (ACE) approach using return-on-investment (ROI) analysis. Uncertainty and sensitivity analyses (Sas) tested the robustness of the model outputs to changes in three assumptions: general practitioner referral pathway (SA1), private setting intervention delivery (SA2), and training costs (SA3). Results: The intervention produced cost savings of A$ 46M (95% UI -223.7 to 73.3) and A$ 18.3M (95% UI -86.2 to 24.6), subject to the effect of intervention lasting 2- or 1-year follow-up. The ROI ratio reduced to 5.22 in SA1 (95% UI -10.1 to 27.9), 2.5 in SA2 (95% UI -4.8 to 13.3), and 5.1 in SA3 (95% UI -9.8 to 27.8). Limitations: We assumed that the effectiveness would reduce 50% within 5 years in the base case, and we used Australian data and a partial social perspective. Conclusions: The current study demonstrated cost-effectiveness of CBT for adults who have self-harmed with the return-on-investment ratio of A$ 2.3 to $6.0 for every A$ 1 invested.

Banning highly hazardous pesticides saves the lives of young people, particularly females, in low- and middle-income countries.

Pesticide self-poisoning is a public health problem mostly affecting low- and middle-income countries. In Sri Lanka, India and China suicide rates have reduced among young people, particularly females, following highly hazardous pesticides (HHP) bans. This success story requires attention to encourage more research on differential effects of HHP bans.

Situation Analysis of Suicide and Self-Harm in the WHO Eastern Mediterranean Region.

OBJECTIVE: An estimated 41,000 lives are lost to suicide each year in World Health Organization Eastern Mediterranean Region Office (WHO EMRO) countries. The objective of this study was to conduct a situation analysis for suicide and self-harm in the WHO EMRO region. METHODS: Data on suicide were obtained from the WHO Global Health Estimates for the years 2000-2019. Information on risk groups efforts to prevent self-harm and suicide in the EMRO region were retrieved through scientific studies, grey literature, and public websites. RESULTS: During 2000-2019, the age-standardized suicide rate was 6.7 per 100,000 inhabitants, albeit there are concerns regarding data quality. Self-harm and suicide remain criminal acts in more than half of the countries. Few countries have a national plan for prevention of suicide. Toxic agents, such as pesticides and black henna, are easily available and frequently used for suicide in some areas, as are firearms and self-immolation. Successful prevention measures include means restriction and psychosocial interventions after self-harm. CONCLUSION: Many WHO EMRO countries remain underserved in terms of mental health care. Decriminalization of suicide and means restriction might be further promoted. Online-based tools for mental health literacy and psychosocial therapy are other options to explore.

Suicidal behavior remains a criminal act in more than half of the WHO EMRO countries.Easily available toxic agents, such as pesticides and black henna, and firearms are common methods used for suicidal behavior in the WHO EMRO countries.Access to mental health care is limited in many of the WHO EMRO countries.Online-based psychoeducation and psychosocial intervention programs might be further explored as preventive efforts.

Modelling the cost-effectiveness of brief aftercare interventions following hospital-treated self-harm.

BACKGROUND: Prior self-harm represents the most significant risk factor for future self-harm or suicide. AIM: To evaluate the cost-effectiveness of a theoretical brief aftercare intervention (involving brief follow-up contact, care coordination and safety planning), following a hospital-treated self-harm episode, for reducing repeated self-harm within the Australian context. METHOD: We employed economic modelling techniques to undertake: (a) a return-on-investment analysis, which compared the cost-savings generated by the intervention with the overall cost of implementing the intervention; and (b) a cost-utility analysis, which compared the net costs of the intervention with health outcomes measured in quality-adjusted life years (QALYs). We considered cost offsets associated with hospital admission for self-harm and the cost of suicide over a period of 10 years in the base case analysis. Uncertainty and one-way sensitivity analyses were also conducted. RESULTS: The brief aftercare intervention resulted in net cost-savings of AUD$7.5 M (95% uncertainty interval: -56.2 M to 15.1 M) and was associated with a gain of 222 (95% uncertainty interval: 45 to 563) QALYs over a 10-year period. The estimated return-on-investment ratio for the intervention's modelled cost in relation to cost-savings was 1.58 (95% uncertainty interval: -0.17 to 5.33). Eighty-seven per cent of uncertainty iterations showed that the intervention could be considered cost-effective, either through cost-savings or with an acceptable cost-effectiveness ratio of 50 000 per QALY gained. The results remained robust across sensitivity analyses. CONCLUSIONS: A theoretical brief aftercare intervention is highly likely to be cost-effective for preventing suicide and self-harm among individuals with a history of self-harm.

Early impacts of the 'National Suicide Prevention Trial' on trends in suicide and hospital admissions for self-harm in Australia.

OBJECTIVES: The National Suicide Prevention Trial was announced by the Australian Government in 2016 and aimed to prevent suicidal behaviour in 12 trial sites (representing a population of ~8 million). This study investigated the early population-level impact of the National Suicide Prevention Trial activity on rates of suicide and hospital admissions for self-harm in comparison to control areas. METHODS: Relative and absolute differences in monthly rates of suicide and hospital admissions for self-harm were compared in the period after the National Suicide Prevention Trial implementation (July 2017-November 2020) to the period prior to implementation (January 2010-June 2017) in (1) 'National Suicide Prevention Trial areas' and (2) 'Control areas', using a difference-in-difference method in a series of negative binomial models. Analyses also investigated whether associations for suicide and self-harm rates differed by key socio-demographic factors, namely sex, age group, area socio-economic status and urban-rural residence. RESULTS: There were no substantial differences between 'National Suicide Prevention Trial areas' and 'Control areas' in rates of suicide (2% relative decrease, relative risk = 0.98, 95% confidence interval = [0.91, 1.06]) or self-harm (1% relative decrease, relative risk = 0.99, 95% confidence interval = [0.96, 1.02]), adjusting for sex, age group and socio-economic status. Stronger relative decreases in self-harm only were evident for those aged 50-64 years, high socio-economic status areas, metropolitan and remote geographic areas. CONCLUSION: There was limited evidence that the National Suicide Prevention Trial resulted in reductions in suicide or hospital admissions for self-harm during the first 4 years of implementation. Continued monitoring of trends with timely data is imperative over the next 2-3 years to ascertain whether there are any subsequent impacts of National Suicide Prevention Trial activities.

Surveillance of Hospital-Presenting Intentional Self-Harm in Western Sydney, Australia, During the Implementation of a New Self-Harm Reporting Field.

Background: Hospital-presenting self-harm is a strong predictor of suicide and has substantial human and health service costs. Aims: We aimed to identify changes in case ascertainment after implementation of a new self-harm reporting field at a tertiary hospital in New South Wales, and to report event rates, demographic, and clinical characteristics. Method: Self-harm events presenting to the emergency department (October 2017 to August 2020) were identified using clinical documentation and a new reporting field. Changes in the frequency of self-harm in the period after implementation of the self-harm field were assessed through Poisson regression models. Results: A twofold increase in the frequency of self-harm was detected following the implementation of the new reporting field. The annual average age-standardized event rate of self-harm was 110.4 per 100,000 (120.8 per 100,000 for females; 100.1 per 100,000 for males). The highest rates by age and sex were for females aged 15-19 years (375 per 100,000) and males aged 20-24 years (175 per 100,000). Limitations: Self-harm identification relies on clinician coding practice, which is subject to variability and potential under-enumeration. Conclusion: These findings highlight the value of a self-harm reporting field in hospital record systems for accurate recording and long-term monitoring of self-harm event rates.

Attributable risk of suicide for populations in Australia.

Objective: Each year approximately 3,000 Australians die by suicide. We estimated the population attributable risk for identified target populations to provide evidence on how much of the overall burden of suicide in the Australian population is experienced by each of them. Methods: We identified 17 demographic and clinical target populations at risk of suicide and calculated the population attributable fraction (PAF) using a single or pooled suicide risk and the proportional representation of each target population within Australia. Results: Large PAF estimates were found for men (52%, 95% confidence interval (CI) 51%-53%), people bereaved by suicide (35%, 95% CI 14%-64%), people with a mental health or behavioural condition (33%, 95%CI 17%-48%), people with a chronic physical condition (27%, 95%CI 18%-35%), adults aged 25-64 years (13%, 95%CI 12%-14%), LGB populations (9%, 95%CI 6%-13%), offenders (9%, 95%CI 8%-10%), and people employed in blue collar occupations (8%, 95%CI 4%-12%). Limitations: The PAF is limited by assumptions, namely, that risk factors are independent, and that the relationship between risk factors and outcomes are unidirectional and constant through time. Conclusions and implications for public health: Considerable reductions in the overall suicide rate in Australia may occur if risk factors are addressed in identified populations with large PAF estimates. These estimates should be considered as an adjunct to other important inputs into suicide prevention policy priorities.

Cost-effectiveness of media reporting guidelines for the prevention of suicide.

INTRODUCTION: Media guidelines for the responsible reporting of suicide are a recognized universal suicide prevention intervention. While implemented in numerous countries, including Australia, little is known about whether they are cost-effective. We aimed to determine the cost-effectiveness of Mindframe, the national initiative implementing media guidelines in Australia. METHOD: We conducted a modelled economic evaluation (5-year time-horizon) incorporating two types of economic analysis: (i) return-on-investment (ROI) comparing estimated cost savings from the intervention to the total intervention cost, and (ii) cost-effectiveness analysis comparing the net intervention costs to health outcomes: suicide deaths prevented and quality-adjusted life-years (QALYs). We also included uncertainty analyses to propagate parameter uncertainty and sensitivity analyses to test the robustness of the model outputs to changes in input parameters and assumptions. RESULTS: The estimated ROI ratio for the main analysis was 94:1 (95% uncertainty interval [UI]: 37 to 170). The intervention was associated with cost savings of A$596M (95% UI: A$228M to A$1,081M), 139 (95% UI: 55 to 252) suicides prevented and 107 (95% UI: 42 to 192) QALYs gained. The intervention was dominant, or cost-saving, compared with no intervention with results being robust to sensitivity analysis but varying based on the conservativeness of the parameters entered. CONCLUSION: Mindframe was found to be cost-saving, and therefore, worthy of investment and inclusion as part of national suicide prevention strategies.

Cost-effectiveness of Installing Barriers at Bridge and Cliff Sites for Suicide Prevention in Australia.

Importance: Installation of barriers has been shown to reduce suicides. To our knowledge, no studies have evaluated the cost-effectiveness of installing barriers at multiple bridge and cliff sites where suicides are known to occur. Objective: To examine the cost-effectiveness of installing barriers at bridge and cliff sites throughout Australia. Design, Setting, and Participants: This economic evaluation used an economic model to examine the costs, costs saved, and reductions in suicides if barriers were installed across identified bridge and cliff sites over 5 and 10 years. Specific and accessible bridge and cliff sites across Australia that reported 2 or more suicides over a 5-year period were identified for analysis. A partial societal perspective (including intervention costs and monetary value associated with preventing suicide deaths) was adopted in the development of the model. Interventions: Barriers installed at bridge and cliff sites. Main Outcomes and Measures: Primary outcome was return on investment (ROI) comparing cost savings with intervention costs. Secondary outcomes included incremental cost-effectiveness ratio (ICER), comprising the difference in costs between installation of barriers and no installation of barriers divided by the difference in reduction of suicide cases. Uncertainty and sensitivity analyses were undertaken to examine the association of changes in suicide rates with barrier installation, adjustments to the value of statistical life, and changes in maintenance costs of barriers. Results: A total of 7 bridges and 19 cliff sites were included in the model. If barriers were installed at bridge sites, an estimated US $145 million (95% uncertainty interval [UI], $90 to $160 million) could be saved in prevented suicides over 5 years, and US $270 million (95% UI, $176 to $298 million) over 10 years. The estimated ROI ratio for building barriers over 10 years at bridges was 2.4 (95% UI, 1.5 to 2.7); the results for cliff sites were not significant (ROI, 2.0; 95% UI, -1.1 to 3.8). The ICER indicated monetary savings due to averted suicides over the intervention cost for bridges, although evidence for similar savings was not significant for cliffs. Results were robust in all sensitivity analyses except when the value of statistical life-year over 5 or 10 years only was used. Conclusions and Relevance: In an economic analysis, barriers were a cost-effective suicide prevention intervention at bridge sites. Further research is required for cliff sites.

The impact of the COVID-19 pandemic on hospital-treated self-harm in Sydney (Australia).

OBJECTIVES: This study investigated trends in hospital-treated self-harm and hospital presenting suicidal ideation in the period before and after COVID-19 public health responses by key socio-demographic groups among those presenting to hospitals in the Western Sydney (Australia) population catchment. METHODS: Emergency department presentations for the period January 2016 to June 2021 were used to specify a series of interrupted time-series models to compare the observed and expected event rates of (1) hospital-treated self-harm and (2) hospital presenting suicidal ideation in the period following the onset of COVID-19 public health measures in March 2020. Rate differences between observed and expected rates in the post-implementation period were also estimated in models stratified by sex, age group, country of birth and socio-economic status. RESULTS: There was no significant increase in hospital-treated self-harm in the period post-implementation of public health orders (March 2020) compared to the previous period, although there were lower than expected rates of emergency department presentations among non-Australian-born males, males aged 0-14 years and 25-44 years, and females aged 45-64 years. In contrast, there was a significant increase in hospital presenting suicidal ideation, particularly among women (rate difference per 100,000 = 3.91, 95% confidence interval = [1.35, 6.48]) and those aged 15-24 years (both males and females, rate differences ranging from 8.91 to 19.04), and among those residing in lower socio-economic status areas (both males and females, rate differences ranging from 0.90 to 2.33). CONCLUSION: There was no increase in hospital-treated self-harm rates in the 15 months post-implementation of COVID-19 public health orders in Western Sydney; however, there was a significant increase in hospital presenting suicidal ideation. The limited change in suicidal behaviour may reflect the success of social and economic supports during this period, the benefits of which may have been different for young people, and those of lower socio-economic status.

Sex education and self-poisoning in Sri Lanka: an explorative analysis.

BACKGROUND: Self-harm and suicide are important causes of morbidity and mortality in Sri Lanka, but our understanding of these behaviours is limited. Qualitative studies have implicated familial and societal expectations around sex and relationships. We conducted an explorative analysis using case-control data to investigate the association between sex education and self-poisoning in Sri Lanka. METHODS: Cases (N=298) were self-poisoning inpatients on a toxicology ward, Teaching Hospital Peradeniya. Controls (N=500) were sex and age frequency matched to cases and were outpatients/visitors to the same hospital. Participants were asked whether they had received sex education, and to rate the quality and usefulness of any sex education received. Logistic regression models adjusted for age, sex, and religion quantified the association between receipt, quality and usefulness of sex education and self-poisoning. We tested whether the associations differed by sex. RESULTS: Roughly 1-in-3 cases and 1-in-5 controls reported having not received sex education. Individuals who did not receive sex education were nearly twice as likely to have self-poisoned than those who did (OR 1.68 (95% CI 1.11-2.55)). Those who reported the sex education they received as not useful were more likely to have self-poisoned compared to those who reported it useful (OR 1.95 (95% CI 1.04-3.65)). We found no evidence of an association between self-poisoning and the self-rated quality of sex education, or that associations differed by participant sex. CONCLUSION: As sex education is potentially modifiable at the population-level, further research should aim to explore this association in more depth, using qualitative methods and validated measurement tools.

Socioeconomic and Geographic Correlates of Intimate Partner Violence in Sri Lanka: Analysis of the 2016 Demographic and Health Survey.

Intimate partner violence (IPV) is a serious public health issue and violation of human rights. The prevalence of IPV in South Asia is especially pronounced. We examined the associations between socioeconomic position (SEP), geographical factors and IPV in Sri Lanka using nationally representative data. Data collected from Sri Lanka's 2016 Demographic and Health Survey were analysed using multilevel logistic regression techniques. A total of 16,390 eligible ever-partnered women aged 15-49 years were included in the analysis. Analyses were also stratified by ethnicity, type of violence, neighbourhood poverty and post-conflict residential status for selected variables. No schooling/primary educational attainment among women (OR 2.46 95% CI 1.83-3.30) and their partners (OR 2.87 95% CI 2.06-4.00), financial insecurity (OR 2.17 95% CI 1.92-2.45) and poor household wealth (OR 2.64 95% CI 2.22-3.13) were the socioeconomic factors that showed the strongest association with any IPV, after adjusting for age and religion. These associations predominately related to physical and/or sexual violence, with weak associations for psychological violence. Women living in a post-conflict environment had a higher risk (OR 2.96 95% CI 2.51-3.49) of IPV compared to other areas. Ethnic minority women (Tamil and Moor) were more likely to reside in post-conflict areas and experience poverty more acutely compared to the majority Sinhala women, which may explain the stronger associations for low SEP, post-conflict residence and IPV found among Tamil and Moor women. Policies and programs to alleviate poverty, as well as community mobilisation and school-based education programs addressing harmful gender norms may be beneficial. Trauma informed approaches are needed in post-conflict settings. Further exploratory studies investigating the complex interplay of individual, household and contextual factors occurring in this setting is required.

Clinical and psychosocial factors associated with domestic violence among men and women in Kandy, Sri Lanka.

Domestic violence (DV) is a violation of human rights with adverse intergenerational consequences on physical and mental health. Clinical and psychosocial correlates of DV have been documented internationally, but evidence from South Asia is limited, especially among men. This is a nested cross-sectional study of the control population (N = 856) of a large case-control study in Kandy, Sri Lanka. Multivariable logistic regression models were conducted to estimate the association between clinical and psychosocial factors and experience of DV. Overall associations were examined and stratified by sex and type of abuse. Overall, 19% (95% CI 16%-21%) of the sample reported DV of any form in past year, with a similar prevalence being reported in both men (18% 95% CI 14%-22%) and women (19% 95% CI 15%-23%). Depression symptoms (adjusted OR [AOR] 3.28 95% CI 2.13-5.05), suicidal ideation (AOR 6.19 95% CI 3.67-10.45), prior diagnosis of a mental illness (AOR 3.62 95% CI 1.61-8.14), and previous self-harm (AOR 6.99 95% CI 3.65-13.38) were strongly associated with DV, as were indicators of perceived poor social support (AOR range 2.48-14.18). The presence of in-laws (AOR 2.16 95% CI 1.34-3.48), having three or more children (AOR 2.15 95% CI 1.05-4.41) and being divorced/separated/widowed were also strongly associated with DV (AOR 2.89 95% CI 1.14-7.36). There was no statistical evidence that any associations differed by sex. A multi-sectoral approach is needed to address DV in this context. Enhanced coordination between DV support services and mental health services may be beneficial. Further research and support for men as well as women is needed.

Domestic violence and self-poisoning in Sri Lanka.

BACKGROUND: There is increasing evidence that domestic violence (DV) is an important risk factor for suicidal behaviour. The level of risk and its contribution to the overall burden of suicidal behaviour among men and women has not been quantified in South Asia. We carried out a large case-control study to examine the association between DV and self-poisoning in Sri Lanka. METHODS: Cases (N = 291) were patients aged ⩾18 years, admitted to a tertiary hospital in Kandy Sri Lanka for self-poisoning. Sex and age frequency matched controls were recruited from the hospital's outpatient department (N = 490) and local population (N = 450). Exposure to DV was collected through the Humiliation, Afraid, Rape, Kick questionnaire. Multivariable logistic regression models were conducted to estimate the association between DV and self-poisoning, and population attributable fractions were calculated. RESULTS: Exposure to at least one type of DV within the previous 12 months was strongly associated with self-poisoning for women [adjusted OR (AOR) 4.08, 95% CI 1.60-4.78] and men (AOR 2.52, 95% CI 1.51-4.21), compared to those reporting no abuse. Among women, the association was strongest for physical violence (AOR 14.07, 95% CI 5.87-33.72), whereas among men, emotional abuse showed the highest risk (AOR 2.75, 95% CI 1.57-4.82). PAF% for exposure to at least one type of DV was 38% (95% CI 32-43) in women and 22% (95% CI 14-29) in men. CONCLUSIONS: Multi-sectoral interventions to address DV including enhanced identification in health care settings, community-based strategies, and integration of DV support and psychological services may substantially reduce suicidal behaviour in Sri Lanka.

Correction: Childhood adversity and self-poisoning: A hospital case control study in Sri Lanka.

[This corrects the article DOI: 10.1371/journal.pone.0242437.].

Is being a 'left-behind' child associated with an increased risk of self-poisoning in adulthood? Findings from a case-control study in Sri Lanka.

PURPOSE: The long-term consequences of parental emigration on offspring self-harm risk is unknown. METHODS: We investigated the association between experiencing parental emigration in childhood with hospital presentations for self-poisoning in adulthood using a hospital case-control study. Cases were adult self-poisoning patients (≥18 year olds) admitted to the medical toxicology ward Teaching Hospital Peradeniya, Sri Lanka. Sex and age frequency matched controls were recruited from the outpatient department or nearby specialist clinics at the same hospital. Details of parental emigration were collected using a pre-piloted questionnaire. The relationship between parental emigration and self-poisoning in adulthood was estimated using logistic regression models. RESULTS: 298 cases, and 500 hospital controls were interviewed for the study. We estimate that one in five adults experienced parental emmigration as children (95% CI 17% to 24%). We find limited evidence that children from households with emigrating parents were more likely to experience adverse childhood experiences than those with non-emigrating parents. We found no statistical evidence of an increased risk of self-poisoning in adulthood in individuals who experienced parental emigration (maternal or paternal) during childhood. There was no statistical evidence that the impact differed by the sex of the participant. CONCLUSION: Adults who experienced parental emigration as children were no more likely to self-poison than adults with non-emigrating parents. Further research using longitudinal data are needed to understand whether any adverse outcomes observed in 'left-behind' children are a consequence of parental emigration or due to factors associated but predate the emigration. Prospective data are also important to investigate whether there are any lasting effects on children who experience parental emigration.

Childhood adversity and self-poisoning: A hospital case control study in Sri Lanka.

INTRODUCTION: Adverse childhood experiences (ACE) have been recognized as an important risk factor for suicidal behaviour among adults, but evidence from low and middle-income countries is lacking. This study explored associations between ACE and hospital admission due to non-fatal self-poisoning in Sri Lanka. METHODS: This was a case-control study. Adults admitted to a tertiary care hospital for medical management of self-poisoning were included as cases, and age and sex matched controls were recruited from the outpatient department. ACE were measured using the World Health Organization's Childhood Adversity Scale. Logistic regression models adjusting for age, sex, ethnicity, and religion were used to quantify the association between ACE and self-poisoning. RESULTS: The study included 235 cases and 451 controls. Cases were 2.5 times (95% CI 1.8, 3.6) more likely to report an ACE than controls and had higher ACE scores. Childhood physical abuse (OR 4.7, 95% CI 1.2, 19.0) and emotional abuse or neglect (OR 3.7, 95% CI 1.3, 10.1, and 3.7, 95% CI 2.3, 6.0 respectively), increased the risk of self-poisoning in adulthood, as did witnessing household violence (OR 2.2, 95% CI 1.4, 3.4), growing up in a household with a mentally ill or suicidal household member (OR 2.1, 95% CI 1.2, 3.4), and experiencing parental death/separation/divorce (OR 3.1, 95% CI 2.0, 4.9) as a child. CONCLUSIONS: Reducing exposures to ACEs should be a priority for prevention of suicide and self-harm in Sri Lanka. Innovative methods to increase support for children facing adversity should be explored.